Transcript Cardiometabolic Syndrome

Linked Metabolic Abnormalities:
• Impaired glucose handling/ insulin
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resistance
Atherogenic dyslipidemia
Endothelial dysfunction
Prothrombotic state
Hemodynamic changes
Proinflammatory state
Excess ovarian testosterone production
Sleep-disordered breathing
Resulting Clinical Conditions:
• Type 2 diabetes
• Essential hypertension
• Polycystic ovary syndrome (PCOS)
• Nonalcoholic fatty liver disease
• Sleep apnea
• Cardiovascular Disease (MI, PVD, Stroke)
• Cancer (Breast, Prostate, Colorectal,
Liver)
Multiple Risk Factor Management
• Obesity
• Glucose Intolerance
• Insulin Resistance
• Lipid Disorders
• Hypertension
• Goals: Minimize Risk of Type 2
Diabetes and Cardiovascular Disease
Glucose Abnormalities:
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IDF:
– FPG >100 mg/dL (5.6 mmol. L) or previously
diagnosed type 2 diabetes
WHO:
– Presence of diabetes, IGT, IFG, insulin resistance
ATP III:
– FBS >110 mg/dL, <126 mg/dL (6.1-7.1 mmol/L )
– (ADA: FBS >100 mg/dL [ 5.6 mmol/L ])
Hypertension:
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IDF:
– BP >130/85 or on Rx for previously
diagnosed hypertension
WHO:
– BP >140/90
NCEP ATP III:
– BP >130/80
Dyslipidemia:
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IDF:
– Triglycerides - >150mg/dL (1.7 mmol /L)
– HDL - <40 mg/dL (men), <50 mg/dL
(women)
WHO:
– Triglycerides - >150 mg/dL (1.7 mmol/L)
– HDL - <35 mg/dL (men), >39 mg/dL)
women
ATP III:
– Same as IDF
Screening/Public Health Approach
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Public Education
Screening for at risk individuals:
– Blood Sugar/ HbA1c
– Lipids
– Blood pressure
– Tobacco use
– Body habitus
– Family history
Life-Style Modification: Is it Important?
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Exercise
– Improves CV fitness, weight control, sensitivity
to insulin, reduces incidence of diabetes
Weight loss
– Improves lipids, insulin sensitivity, BP levels,
reduces incidence of diabetes
• Goals:
Brisk walking - 30 min./day
10% reduction in body wt.
Smoking Cessation / Avoidance:
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A risk factor for development in children and adults
Both passive and active exposure harmful
A major risk factor for:
– insulin resistance and metabolic syndrome
– macrovascular disease (PVD, MI, Stroke)
– microvascular complications of diabetes
– pulmonary disease, etc.
Diabetes Control - How Important?
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For every 1% rise in Hb A1c there is an 18% rise in risk
of cardiovascular events & a 28% increase in peripheral
arterial disease
Evidence is accumulating to show that tight blood sugar
control in both Type 1 and Type 2 diabetes reduces risk
of CVD
Goals:
FBS - premeal <110,
postmeal <180.
HbA1c <7%
Overcome Insulin Resistance/ Diabetes:
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Insulin Sensitizers:
– Biguanides - metformin
– PPAR α, γ & δ agonists – Glitazones, Gltazars
Rosiglitazon, Pioglitazon
– Can be used in combination
Insulin Secretagogues:
– Sulfonylurea - glipizide, glyburide,
glimeparide, glibenclamide
– Meglitinides - repaglanide, netiglamide
BP Control - How Important?
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MRFIT and Framingham Heart Studies:
– Conclusively proved the increased risk of
CVD with long-term sustained hypertension
– Demonstrated a 10 year risk of cardiovascular
disease in treated patients vs non-treated
patients to be 0.40.
– 40% reduction in stroke with control of HTN
Precedes literature on Metabolic Syndrome
Goal: BP.<130/80
Lipid Control - How Important?
• Multiple major studies show 24 - 37%
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reductions in cardiovascular disease risk with
use of statins and fibrates in the control of
hyperlipidemia.
Goals: LDL <100 mg/dL (<3.0 mmol /l)
(high risk <70 mg/dL- <2.6 mmol/L)
TG <150 mg% (<1.7 mmol /l)
HDL >40 mg% (>1.1 mmol /l)
Medications:
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Hypertension:
– ACE inhibitors, ARBs
– Others - thiazides, calcium channel
blockers, beta blockers, alpha blockers
– Central acting Alfa agonist : Moxolidin
Dylipidemia:
– Statins, Fibrates, Niacin
Platelet inhibitors:
– ASA, clopidogrel
A Critical Look at the Metabolic Syndrome
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Is it a Syndrome?*
“…too much clinically important information
is missing to warrant its designations as a
syndrome.”
Unclear pathogenesis, Insulin resistance
may not underlie all factors, & is not a
consistent finding in some definitions.
CVD risks associated with metabolic
syndrome has not shown to be greater than
the sum of it’s individual components.
*ADA & EASD
A Critical Look at the Metabolic Syndrome
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clinicians should evaluate and treat all CVD
risk factors without regard to whether a
patient meets the criteria for diagnosis of
the ‘metabolic syndrome’.”
The advice remains to treat individual risk
factors when present & to prescribe
therapeutic lifestyle changes & weight
management for obese patients with
multiple risk factors.
Individual metabolic abnormalities among Qatari
population according to gender (Musallam et al 08)
Men (n = 405)
Women (n=412)
Variable n(%)
ATP III
n(%)
p-Value
Abdominal obesity
227(56.0)
308(74.8)
<0.001
Hypertension
143(35.3)
156(37.9)
0.448
Diabetes
77(19.0)
107(26.0)
0.017
Hypertriglyceridemia
113(27.9)
83(20.1)
0.009
Low HDL
95(23.5)
121(29.4)
0.055
Individual metabolic abnormalities among Qatari
population according to gender
No of components of ATP III
Men (n = 405)
Variable n(%)
n(%)
Women (n=412)
p-Value
None
88(21.7)
74(18.0) –
One
103(25.4)
100(24.3)
Two
125(30.9)
111(26.9) –
Three or more
89(22.0)
127(30.8) –
0.033
Multivariate logistic regression analysis of
factors associated with Metabolic Syndrome
according to (ATP III criteria)
Age
Female gender
Odds ratio
95% CI
p-Value
1.07 1.05–1.09
<0.001
1.86
1.30–2.67
0.001
Body Mass Index 1.05
1.02–1.07
<0.001
Fam his of DM
1.66
1.12–2.44
0.011
Smoking
3.27
1.63–6.55
0.001
Prevalence of MeS in different Countries
Country
Year
Sample
Prevalence
(%)
Arab Americans
2003
542
23
Oman
2001
1419
21
Jordan
2002
1121
36
Saudi Arabia
2004
2250
20.8
Palestine
1998
Qatar
2007
817
27.6
Turkey
2004
1637
33.4*
Iran
?
10368
33.7
* Crude rates
17*
Mussallam et al. Int J Food Safety and PH 2008
Prevalence of MeS in different Countries
Country
Year
Sample
Prevalence
(%)
USA
2005
2002
34*
Greece
2005
1419
21
South Australia
2005
4060
15.3
S. Korea
2001
40,698
6.8
China
2000
2776
10.2*
Turkey
2004
1637
33.4*
Chennai India
2003
475
41*
Qatar
2001
817
27.6
* Crude rates
Mussallam et al. Int J Food Safety and PH 2008